Short Description
Support and participates in the Patient-centered Medical Home (PCMH) concepts of care coordination and team- based care.
Assess, plan, implement, coordinate, monitor and evaluate healthcare options and services with the goal of increasing the likelihood of improvement to the health status of identified populations across the continuum.
* Follow established PCC workflow for utilization and self-management support
* Participate in PCMH activities which include but are not limited to: hospital discharge follow-up, care planning, coordination of services, and communication between care providers
* Collaborate with patient's medical/health and community-based providers to establish mutual goal-setting including patients and their families/caregivers, utilizing self-management tools.
* Provide outreach, care management and education for disease self-management per patient centered goals.
* Identify, document, and mitigate patient barriers to improved outcomes.
* Monitor and evaluate the services and community based resources necessary to respond to the individual member's health needs.
* Provides telephonic and or in-practice outreach, disease management and/or case management, education, and other clinically based activities for target populations.
* Conduct assessments, develop nursing treatment plans and interventions and set goals for treatment plans/behavioral modifications within the scope of licensure in collaboration with other care providers.
* Assists physicians and other team members in developing and implementing evidence based practices and care plans for target health populations.
* Collect data on quality metrics and track as required for improvement efforts.
* Participate in process/quality improvement initiatives to achieve targets as defined by organizational/department goals and objectives.
This is not a remote position. Hours are M-F daytime required to work 2 days a week.
Experience Required
5 years or more clinical experience, Experience in primary care, population or case management preferred..
Education Requirements
RN, (BSN) preferred.
License/Certification Requirements
Current NJ RN License